Provider Demographics
NPI:1962997544
Name:MENNEAR, WESLEY ALBERT (DPT)
Entity type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:ALBERT
Last Name:MENNEAR
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3066 E MERIDIAN PARK LOOP STE 3
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7254
Mailing Address - Country:US
Mailing Address - Phone:907-357-7710
Mailing Address - Fax:
Practice Address - Street 1:3190 E MERIDIAN PARK LOOP STE 206A
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7422
Practice Address - Country:US
Practice Address - Phone:907-373-9462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK133975225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK133975OtherPROFESSIONAL LICENSE